Medical Student Documentation

April 2, 2004

1. Medical students can obtain the following information from a patient outside the presence of a teaching physician or resident and document in the medical record:
   1. Review of Systems

   2. Past Family History

   3. Past Social History

   4. Past Medical/Surgical History
2. Teaching Physicians may not refer to or rely on a student's documentation of physical exam findings, medical decision making, or history of present illness in their personal notes.
3. If the medical student documents E/M services, the teaching physician must verify and redocument the history of present illness as well as perform and redocument the physical exam and medical decision making activities of the service.